Just two days after the House Commerce Subcommittee on Health and the Environment held a hearing on a bill (H.R. 4807) that would reauthorize the Ryan White CARE Act (P.L. 101-381), the House Commerce Committee on July 13 approved the bill by voice vote.
The Ryan White CARE Act was first passed in 1990 and reauthorized by Congress in 1996. The Act provides emergency assistance to those cities with the largest number of AIDS cases. In order to qualify for funding, cities must have a population of 500,000 as well as 2,000 newly diagnosed AIDS cases in the previous five years. Cities may use the funds to increase and improve the quality and availability of health and support services for HIV-infected individuals and their families, including outpatient services, substance abuse and mental health treatment, and drug therapy; to provide early intervention services, including HIV testing for high-risk individuals; and to hire and train health care personnel and support staff. Funding streams for the Act are divided into five titles.
H.R. 4807 would reauthorize CARE programs through FY2005. The legislation makes several changes in current law in an effort to provide services to a greater number of individuals and to better aid communities with the greatest need.
Under H.R. 4807, which represents a bipartisan compromise between bill sponsors Reps. Tom Coburn (R-OK) and Henry Waxman (D-CA), the number of HIV infections would be added to the criteria for determining grant assistance; however, the bill would not implement this change until 2005. Currently, cities receive funding based solely on the number of reported AIDS cases, not on the number of HIV infections. Many states began reporting HIV infections in 1985, but according to the Centers for Disease Control and Prevention (CDC), only 33 states have CDC-approved reporting systems in place.
According to testimony by Janet Heinrich of the General Accounting Office at the July 11 hearing, the CDC expects that all states will be reporting HIV infections by the year 2003; however, an additional one to three years would be needed to ensure that all HIV infections are entered into the system. As such, the bill includes language requiring the Secretary of Health and Human Services to determine the extent to which data on HIV infections is available prior to implementing the funding formula change. If the Secretary makes the determination that the data is not available, then the funding formula would not change.
Stating that H.R. 4807 would shift the focus of the CARE Act from AIDS cases to HIV infections, Rep. Coburn stated, “Those with HIV are too often not figured into the care component,” adding: “The Act will have an emphasis on prevention.” Rep. Waxman agreed, saying, “Our bill responds to changes in the epidemic by focusing on HIV-infected people not receiving care.”
The bill would provide additional grants to states that have enacted laws requiring mandatory newborn testing. The additional funding would be made available to these states to implement mandatory newborn testing. The Institute of Medicine (IOM) also would be required to study the number of infants born with HIV and the barriers that may prevent an obstetrician from routinely screening pregnant women and infants for HIV. The study also would make recommendations for states to reduce the cases of perinatal transmission of HIV.
The bill would provide additional grants for states that have implemented partner notification programs. The funding would be used by states to aid in the implementation of those programs.
H.R. 4807 also would change the funding formula in an effort to ensure a more equitable distribution of funding. Under the original 1990 Act, funding was distributed to eligible metropolitan areas (EMAs) based on the number of cumulative AIDS cases, which included individuals living with AIDS as well as those who had died from AIDS. However, the 1996 reauthorization changed the funding distribution so that it was based on the estimated number of living AIDS cases. Noting that this shift would cause a burden on certain EMAs, authorizers included a hold harmless provision that gradually implemented the funding change over a five-year period. Under the 1996 hold harmless provision, at the end of the five-year period, EMAs were guaranteed to receive at least 95 percent of the funds they received in the previous fiscal year (FY1999).
H.R. 4807 would phase-in another change to the hold harmless provision. EMAs would be guaranteed to receive 98 percent of funds the first year, 95.7 percent the second year, 91.1 percent the third year, 84.2 percent the fourth year, and 75 percent the fifth year.
The committee adopted, by voice vote, a technical amendment by Rep. Coburn. The amendment incorporates language authored by Rep. Edolphus Towns (D-NY) to ensure that the membership of the HIV Health Services Planning Councils established under the CARE Act reflects the demographics of the population of individuals infected with HIV. The amendment also includes language authored by Rep. Diana DeGette (D-CO) that would alter the hold harmless provision for Title II funds only. The amendment would ensure that EMAs received a 5 percent reduction over the five-year period, rather than the 25 percent reduction.
Responding to concerns by the administration, the Coburn amendment also would allow funding for community prevention activities under Titles I and II to be used for primary care services. The committee also adopted, by voice vote, an amendment by Rep. Ted Strickland (D-OH) that would expand public participation in the planning councils.
Rep. Anna Eshoo (D-CA) offered and withdrew an amendment that would have changed the hold harmless provision for Title I funds to protect San Francisco’s funding. The amendment would have reduced the five-year reduction in funds from 25 percent to 10 percent. The amendment is identical to a provision in the Senate-passed bill (S. 2311).
Rep. Diana DeGette (D-CO) offered and withdrew an amendment that would have allowed pregnant women to access health care coverage through the State Children’s Health Insurance Program (SCHIP). The amendment was identical to a bill (H.R. 827) that she has sponsored.
Subcommittee Action During the subcommittee hearing, Subcommittee Chair Michael Bilirakis (R-FL) noted the changing face of HIV/AIDS, saying, “H.R. 4807 recognizes that women and minorities increasingly comprise a larger percentage of new cases of HIV in the United States. This demographic shift has not been addressed under existing law.” Testifying on behalf of the administration, Dr. Claude Earl Fox of the Health Resources and Services Administration (HRSA) generally praised H.R 4807 while detailing a few concerns with the bill. Among the concerns outlined by Dr. Fox was a provision dealing with mandatory newborn testing. Noting that the administration placed a high priority on reducing mother-to-child HIV transmission, Dr. Fox stated, “If the national goal is to prevent HIV transmission from mothers to children, the federal government should support, not undermine, prenatal testing and other state-based prevention efforts.” Rep. Coburn disagreed with the administration’s viewpoint, arguing: “With what we know today, we can prevent all perinatal transmission. Why wouldn’t we do that?” The subcommittee also heard from HIV/AIDS advocates who unanimously expressed their support for reauthorization of the CARE Act. “We must look forward, modernize the Act and ensure that it can meet the demands and challenges facing the HIV/AIDS communities,” stated Jeanne White, the mother of Ryan White, for whom the Act is named. Dorothy Mann of the AIDS Alliance for Children, Youth, and Families added: “Every day throughout this nation, the CARE Act is saving the lives of children, youth, and adults with HIV. By renewing this program, you will also help to renew our nation’s commitment to people living with HIV.”
